During on call, an elderly man with a lot of health problems suddenly take a turn for the worse. He is on Warfarin, a blood thinner, and has come in because his INR was too high (blood was too thin due to having too much Warfarin in the body). When we rush him down for a CT of the brain, we realise he's had a massive bleed in the head.

We reverse the Warfarin immediately with vitamin K and fresh frozen plasma, but that only stems the bleeding. There is still a large pool of blood in his head that's compressing his brain and slowly but surely killing him.

I contact the neurosurgery resident on call. He sees the films and reviews the patient's past medical history. Neurosurgery is very picky about their surgical candidates. Because neurosurgery is so difficult to perform and risks so high, often the surgical candidates are the young and previously healthy (who will most likely survive the surgery and benefit most from it) but ill enough to warrant surgery (because the risks are high).

Sadly, my man only fulfills the latter criteria. The neurosurgeons say there is no surgery they can offer the man that would make any significant change to his current situation. He will likely die on the operating table if they operate and they would not take that risk.

So the only thing that remains is we try to medically stabilise him -- lower the intracranial pressure (pressure in his brain due to the bleeding) -- and support his vitals with IV fluids and monitoring. He will probably die.

I speak to the family. There is nothing major we can do to reverse the pool of blood in his brain. If he survives our supportive treatment, then he will probably not have much of a quality of life, but we will try. If he deteriorates and stops breathing or his heart stops beating, CPR won't remove the pool of blood. It will just make his death traumatic and, at most, prolong this phase where he is unresponsive to the world (and with broken ribs from CPR and a tube shoved down his throat) before dying. If the family agrees, I will put in a DNACPR but continue best supportive treatment.

After discussion between the four offsprings and a traumatised wife, the oldest daughter turns to me.

"We want to proceed with the neurosurgery."

Record scratch.

"That's not what I'm offering," I say. "We physicians can't offer neurosurgery. Neurosurgery has said they cannot and will not offer surgery to this man. We physicians can offer CPR and intubation if he dies, but it won't be in his interest. This discussion is around CPR."

"But if the surgeons won't operate, we're just waiting for him to die."

She's right. But even if they operate, he will die anyway.

"I would rather he has that chance and dies on the operating table than just sit and wait for him to die," she says.

Alas, that's not her choice to make.

I sympathise with her wanting every possible option for her father. But she doesn't understand that neurosurgery is not one of those options and probably has false high hopes of the effect of neurosurgery -- I can imagine even if he lives through the surgery, he will be alive, but he will be permanently vegetative, won't be able to talk or express himself, will be fed with a nasogastric (stomach) tube, and just wait to get severe infection from bed sores or pneumonia or UTIs before dying a long, drawn-out death. Obviously, I can only tell her neurosurgeons have decided her father will not benefit from the surgery; it was not my decision either and I won't pretend to know the reasons behind it, as I'm no neurosurgeon myself.

Luckily the family doesn't blame us for lack of neurosurgical options. It would be an unreasonable but not unexpected jump because I'm the messenger of bad news.

The family agree on a DNACPR, because they also realise resuscitation won't change his current situation. We keep him comfortable, continue supportive treatment, and he dies peacefully several days later with his family by his side.